Generated Narrative: StructureDefinition MyHealthEuImagingReport Name Flags Card. Type Description & Constraints MyHealthEuImagingReport 0..* EHDSImagingReport MyHealth@EU Imaging report model Elements defined in Ancestors:header, header, presentedForm, header, body, <a href="http://www.xt-ehr.eu/fhir/models/0.3.0/StructureDefinition-EHDSImagingReport.html" title="Metadata of the DICOM study. A study comprises a set of series, each of which includes a set of Service-Object Pair Instances (SOP Instances - images or other data) acquired or produced in a common context. A series is of only one modality (e.g. X-ray, CT, MR, ultrasound), but a study may have multiple series of different modalities.">dicomStudyMetadata, attachments #xD; header #xD; subject 1..1 MyHealthEuPatient Patient/subject information #xD; identifier O 1..* Identifier Unique identifier of the document Obligations Actor SHALL:handle Imaging Handler SHOULD:handle Imaging Handler #xD; author[x] 1..* The author of the report. #xD; authorMyHealthEuHealthProfessional MyHealthEuHealthProfessional #xD; authorMyHealthEuOrganisation MyHealthEuOrganisation #xD; authorMyHealthEuDevice MyHealthEuDevice #xD; date O 1..1 dateTime Date of finalising/issuing the document Obligations Actor SHOULD:handle Imaging Handler SHOULD:handle Imaging Handler #xD; status O 1..1 CodeableConcept Status of the report Obligations Actor SHALL:handle Imaging Handler SHALL:handle Imaging Handler #xD; language O 0..1 CodeableConcept Language in which the resource is written. Language is expressed by the IETF language tag. Obligations Actor SHALL:handle Imaging Handler #xD; documentType O 1..1 CodeableConcept Type of document (e.g. 18748-4 Diagnostic imaging study) Obligations Actor SHALL:handle Imaging Handler #xD; documentTitle O 1..1 string Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024' Obligations Actor SHALL:handle Imaging Handler #xD; version O 0..1 string Business version of the document. The exact algorithm for versioning is decided by the producer/custodian Obligations Actor SHALL:handle Imaging Handler #xD; attestation #xD; attester[x] 1..1 EHDSHealthProfessional Attester who validated the document #xD; name O 0..1 EHDSHumanName Name of the health professional that has been treating or taking responsibility for the patient. Obligations Actor SHOULD:handle Imaging Handler #xD; professionalRole #xD; organisation O 0..1 EHDSOrganisation The organisation where this role is available Obligations Actor SHOULD:handle Imaging Handler #xD; legalAuthentication O 1..* Base Document legal authentication details Obligations Actor SHOULD:handle Imaging Handler #xD; legalAuthenticator[x] 1..1 The person or organisation taking responsibility for the medical content of the document (typically the person who signs it) #xD; legalAuthenticatorMyHealthEuHealthProfessional MyHealthEuHealthProfessional #xD; legalAuthenticatorMyHealthEuOrganisation MyHealthEuOrganisation #xD; eventType O 0..* CodeableConcept Categorisation of the event covered by the document (e.g. imaging study types, body regions, modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes. Obligations Actor SHALL:handle Imaging Handler SHOULD:handle Imaging Handler #xD; custodian O 0..1 MyHealthEuOrganisation Organisation that is in charge of maintaining the document/report. Obligations Actor SHOULD:handle Imaging Handler #xD; accessionNumber O 0..* Identifier Accession number - an identifier, managed by the RIS at the local level, which usually uniquely identifies an imaging procedure request, and links it to imaging study(ies) and related imaging report(s). Obligations Actor SHALL:handle Imaging Handler #xD; intendedRecipient[x] 0..* Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable #xD; intendedRecipientMyHealthEuPatient MyHealthEuPatient #xD; intendedRecipientEHDSRelatedPerson EHDSRelatedPerson #xD; intendedRecipientMyHealthEuHealthProfessional MyHealthEuHealthProfessional #xD; intendedRecipientMyHealthEuOrganisation MyHealthEuOrganisation #xD; body #xD; orderInformation #xD; orderPlacer[x] O 0..1 The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself. Obligations Actor SHOULD:handle Imaging Handler #xD; orderPlacerMyHealthEuHealthProfessional MyHealthEuHealthProfessional #xD; orderPlacerMyHealthEuOrganisation MyHealthEuOrganisation #xD; orderPlacerMyHealthEuPatient MyHealthEuPatient #xD; orderReason[x] O 0..* CodeableConcept, EHDSCondition, EHDSObservation, string An explanation or justification for why this service is being requested. Obligations Actor SHOULD:handle Imaging Handler #xD; specimen 0..* MyHealthEuSpecimen Specimen information. Note: A specimen (not attached to a body) can be used for diagnostic, forensic and medical research purposes. #xD; examinationReport #xD; modality O 1..* CodeableConcept Imaging modality (or modalities) used during imaging investigation (DICOM CID029). Obligations Actor SHOULD:handle Imaging Handler #xD; imagingProcedures 0..* MyHealthEuProcedure Imaging procedure performed during imaging study. #xD; medicationAdministration 0..* MyHealthEuMedicationAdministration Information about medications administered (contrast, sedation, stress agents, etc) during the procedure. #xD; adverseReaction 0..* MyHealthEuAllergyIntolerance Adverse reactions manifested during imaging investigation. #xD; results[x] 0..* MyHealthEuObservation Imaging report result data (report could consist of multiple observations) #xD; conclusion #xD; impression O 1..1 string Narrative description of the clinical conclusion (impression). Obligations Actor SHOULD:handle Imaging Handler #xD; conditionOrFinding[x] 0..* Condition or finding from imaging investigation. #xD; conditionOrFindingMyHealthEuCondition MyHealthEuCondition #xD; conditionOrFindingMyHealthEuObservation MyHealthEuObservation #xD; recommendation #xD; description O 1..1 string Narrative description of the recommended activities including additional test, medication etc. Obligations Actor MAY:able-to-populate Imaging Handler #xD; carePlan O 0..* EHDSCarePlan A complex and structured information about recommended goals, activities and objectives in the form of one or more formal care plan. Obligations Actor MAY:able-to-populate Imaging Handler #xD; comparisonStudy 0..* MyHealthEuImagingReport Documentation (reference) of a prior Imaging Report to which the current images were compared. #xD; dicomStudyMetadata O 0..* MyHealthEuImagingStudy Metadata of the DICOM study. A study comprises a set of series, each of which includes a set of Service-Object Pair Instances (SOP Instances - images or other data) acquired or produced in a common context. A series is of only one modality (e.g. X-ray, CT, MR, ultrasound), but a study may have multiple series of different modalities. Obligations Actor SHALL:handle Imaging Handler #xD; attachments O 0..* EHDSAttachment Report attachments Obligations Actor SHOULD:handle Imaging Handler #xD; Documentation for this format
MyHealthEu refined model for the imaging report
Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).
Date and optionally time of authoring/issuing
Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.
Language in which the resource is written. Language is expressed by the IETF language tag.
Type of document (e.g. 18748-4 Diagnostic imaging study)
Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'
Time of service that is being documented
Business version of the document. The exact algorithm for versioning is decided by the producer/custodian
An identifier of the health professional that is unique within a defined scope. Example: National health professional ID. Multiple identifiers could be provided.
Name of the health professional that has been treating or taking responsibility for the patient.
Mailing and office or home addresses. The addresses are always sequences of address parts (e.g. street address line, country, postcode, city) even if postal address formats may vary depending on the country. An address may or may not include a specific use code; if this attribute is not present it is assumed to be the default address useful for any purpose.
Telecommunication contact information (addresses) associated with a person, such as phone number, email, or messaging service. Multiple telecommunication addresses might be provided.
Professional role that the health professional is practicing at a given organisation. This is a generalisation of the FHIR PractitionerRole resource, which is used to represent the role of a practitioner in a specific context, such as a specific organisation or location.
Health professional role. Multiple roles could be provided.
The organisation where this role is available
The specialty of a practitioner that describes the functional role they are practicing at a given organisation
Date and time of the approval of the document by Attester
The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)
Date and time when the document was authorised
Categorisation of the event covered by the document (e.g. imaging study types, body regions, modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.
Additional details about where the content was created (e.g. clinical specialty)
Organisation that is in charge of maintaining the document/report.
A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Accession number - an identifier, managed by the RIS at the local level, which usually uniquely identifies an imaging procedure request, and links it to imaging study(ies) and related imaging report(s).
Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable
Order Information (Imaging Result Report could respond to multiple orders).
Identifier(s) of the imaging service order.
The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself.
An explanation or justification for why this service is being requested.
Specification of clinical question (goal of the investigation) to be answered by the imaging investigation.
Additional clinical information about the patient or specimen that may affect service delivery or interpretation (additional types of information may be allowed in implementations).
This information includes diagnosis, clinical findings and other observations. This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the metal implants present in patient's body.
Clinical findings and other observations (e.g., height and weights of the patient).
Conditions that may influence the service or result interpretation.
Medication administered before ordering the service specifically for this procedure.
List of implants or devices that affect the course of the examination or its interpretation (e.g. metal implants).
Pregnancy status when the imaging examination was performed (e.g., pregnant, not pregnant, unknown).
Sex parameter for clinical use - provides guidance on how a recipient should apply settings or reference ranges that are derived from observable information such as an organ inventory, recent hormone lab tests, genetic testing, menstrual status, obstetric history, etc. This property is intended for use in clinical decision making, and indicates that treatment or diagnostic tests should consider best practices associated with the relevant reference population.
Specimen information. Note: A specimen (not attached to a body) can be used for diagnostic, forensic and medical research purposes.
Information on total exposure to ionising radiation. This information is required by regulations in several EU countries.
eHN Guideline IMG (v1.1): B.1.4.4, Article 2 Imaging report definition
Imaging modality (or modalities) used during imaging investigation (DICOM CID029).
Imaging procedure performed during imaging study.
Information about medications administered (contrast, sedation, stress agents, etc) during the procedure.
Adverse reactions manifested during imaging investigation.
Imaging report result data (report could consist of multiple observations)
A concise and clinically contextualised summary including interpretation/impression of the diagnostic report.
Narrative description of the clinical conclusion (impression).
Condition or finding from imaging investigation.
Recommendation section for additional imaging tests or other actions
Narrative description of the recommended activities including additional test, medication etc.
A complex and structured information about recommended goals, activities and objectives in the form of one or more formal care plan.
Documentation (reference) of a prior Imaging Report to which the current images were compared.
Metadata of the DICOM study. A study comprises a set of series, each of which includes a set of Service-Object Pair Instances (SOP Instances - images or other data) acquired or produced in a common context. A series is of only one modality (e.g. X-ray, CT, MR, ultrasound), but a study may have multiple series of different modalities.